Summary A Royal Airlines Airbus A310, Flight 4522, registration C-GRYV, took off from Runway32 at the Ottawa / Macdonald-Cartier International Airport en route to JohnF.Kennedy International Airport in New York City. About one minute later, an Air Canada Bombardier Regional Jet (RJ), Flight662, registration C-FZAQ, took off from Runway25 at the Ottawa International Airport, en route to Boston, Massachusetts. Both were cleared to maintain 15000feet and were then handed off to the Valley sector of the Montral Area Control Centre. At that time the Airbus was about 10nautical miles (nm) north of, and slightly behind, the RJ and was on a heading of 140 . The RJ was on a heading of about 130 proceeding directly to the Massena VOR (VHF omnidirectional radio range). Both aircraft were cleared to maintain flight level190 (FL190) and then FL220. A loss of separation occurred when the aircraft closed to 3.7nm with less than 1000feet of vertical separation. Subsequently, the Airbus, at FL230, conflicted with C-GLEM, a Piaggio P-180 at FL230 inbound to St. Hubert, Quebec. These aircraft approached to 3 nm. The minimum separation required in both instances was 5nm lateral or 1000feet vertical spacing. Ce rapport est galement disponible en franais. Other Factual Information The air traffic controller at the time of the first incident was a trainee under the supervision of an on-job instructor (OJI). The Valley sector trainee controller had three years' experience as a controller and had been under training in the Valley sector of the west specialty subunit of the Montral Area Control Centre (ACC) for five months. The OJI was controlling at the time of the second incident. The Valley sector OJI had nine years' experience as a controller and seven years' experience in the west specialty. Both controllers were working the fifth day of their shift cycle. They had been on duty for approximately two hours on the day of the occurrence and for approximately 30minutes since the last relief break. Workload was described as moderate. The Airbus took off at 16311 and was given a right turn to a heading of 140 . At 1637:05, the Airbus captain contacted the Valley controller and advised that they were climbing through 11600feet on their way to 15000feet and were on the assigned heading of 140 . The Regional Jet (RJ) took off at 1632 and was given a left turn to a heading of 140 until able to proceed direct to the Massena VOR (VHF omnidirectional radio range). At 1636:50, when about 14nautical miles (nm) south of Ottawa, the RJ crew contacted the Valley controller advising that they were through 12400feet climbing to 15000feet and were proceeding direct to the Massena VOR. After passing the Massena VOR, the RJ's route was to take it southeasterly toward a VOR north of Boston; the route of the Airbus after Massena was to continue southbound to JohnF.Kennedy International Airport. The controller's aim was to enable the aircraft to cross tracks with appropriate vertical separation as they approached the Massena VOR before exiting Canadian airspace. The Valley controller monitored the climb and issued matching climb limits to flight level (FL)190 and later to FL220 for both aircraft as they approached the Massena VOR. Shortly after the Valley controller cleared the Airbus to FL220, the OJI, having recognized the converging flight paths of the aircraft, advised the Valley controller that the control strategy being implemented was not going to work. The aircraft were 7 nm apart and converging at an angle of approximately 10 . The Valley controller then directed the Airbus to maintain FL200 and, for the climb, to turn left three zero degrees. The Nav Canada Air Traffic Control Manual of Operations(ATC MANOPS), article507, directs controllers to issue a safety alert to an aircraft if you are aware the aircraft is at an altitude which, in your judgement, places it in unsafe proximity to the terrain, an obstruction or another aircraft. The recommended phraseology to alert a pilot to conflicting traffic is as follows: TRAFFIC ALERT (position of traffic, if time permits), ADVISE YOU TURN RIGHT/LEFT (specific heading, if appropriate), or CLIMB/DESCEND (specific altitude, if appropriate) IMMEDIATELY. The Valley controller did not issue a safety alert using the phraseology recommended in ATC MANOPS. ATC MANOPS, Part9, provides direction to controllers on the methods of recording aircraft altitudes on flight progress strips. When the Valley controller cleared the Airbus from FL220 to FL200, the new flight level was not entered on the flight progress strip for the Airbus; however, the flight progress strip for the RJ shows 200 in the altitude box. A clearance of FL200 was not issued to the RJ throughout the radio exchanges, though the OJI advised the crew to stop the climb when at approximately FL202. ATC MANOPS, article 543.1, specifies three methods by which a controller may issue radar vectors to aircraft. The choices include specifying the heading to be flown, specifying the direction of the turn and the heading to be flown after the completion of the turn, or specifying the direction and the number of degrees to turn. The Valley controller specified the direction and the number of degrees to turn. The standard division of work between the captain and the first officer of the Airbus required that, when above 10000feet on departure, the pilot not flying would transmit the departure message on the company frequency. When the Valley controller instructed the Airbus to maintain FL200 and for the climb to turn left three zero degrees, the first officer was in contact with the company, and the captain was flying the aircraft with the autopilot. The captain was monitoring the company frequency and the air traffic control frequency. The captain misheard the clearance from the Valley controller and requested confirmation that the clearance was to climb to FL300. As well, he repeated what he thought was the instruction to turn right to a heading of 170 (30right). The Airbus began a right turn but then reversed when the Valley controller repeated the instruction to turn left 30. By the time the captain was able to reverse the turn, the aircraft had turned through approximately 20 and closed to 3.7nm from the RJ. At the time, the aircraft were separated vertically by approximately 800feet (AppendixA,Figure1). The captain of the Airbus reported seeing the symbol for the RJ on the cockpit traffic alert and collision-avoidance system (TCAS) display. However, the relative geometry of the two aircraft did not meet the requirements for the generation of a traffic alert or a resolution advisory. After a repeat request by the Airbus pilot to confirm that the clearance was to climb to FL300, the Valley controller transmitted a message using the prefix for the RJ, Air Canada, but the flight number for the Airbus, with the message to maintain FL220 and to turn left now. Neither aircraft responded to the transmission. After the Valley controller's transmission using the prefix of the RJ and the flight number of the Airbus, the OJI took control of the radio and directed the RJ to stop the climb immediately and to turn right 30 . The RJ crew acknowledged. The OJI then cleared the Airbus to continue climbing to FL230. The Airbus acknowledged and advised in the left turn to a heading of 110 (as previously instructed by the trainee). This investigation, and others, have found that OJIs are hesitant to intervene too soon to rectify trainee hesitations or errors, believing that trainees, to learn, must be permitted to make their own decisions. OJIs have expressed the sentiment that early intervention will demoralize the trainee and reduce training effectiveness. At 1641:25, as the aircraft were approaching the airspace boundary between Montral ACC and Boston Air Route Traffic Control Center (ARTCC), the OJI initiated handoff communications with the Boston ARTCC controller. After completing the exchange and issuing a clearance to the RJ at 1641:55, he noticed the approaching conflict between the Airbus and a Piaggio P-180. The Airbus was at FL230 on a heading of approximately 115 . The Piaggio P-180 was also at FL230 over the Massena VOR approximately 4 nm south of (to the right of) the Airbus. The OJI issued an instruction to the Airbus to turn right immediately to a heading of 080. Without waiting for a reply, the OJI then issued an instruction to the Piaggio P-180 to turn right to a heading of 150 immediately. This instruction was followed by a third transmission from the OJI, the first part of which was to the Piaggio P-180 repeating the instruction to turn right to a heading of 150 and continuing without interruption to the Airbus to turn left to a heading of 060. The crew of the Airbus stayed on their heading of 110 , and the Piaggio P-180 crew turned right. The two aircraft approached to within 3nm while at the same flight level (AppendixA,Figure2). The OJI did not issue a safety alert using the phraseology recommended in ATC MANOPS. The pilot of the Airbus did not see the Piaggio P-180 or notice the aircraft's intruder symbol on the cockpit TCAS display, and the relative geometry of the two aircraft did not meet the requirements for the generation of a traffic alert or a resolution advisory. The pilot of the Piaggio P-180, after receiving further instructions from the OJI to descend, reported that the Airbus was in sight. In 1997, the TSB issued Aviation Safety Advisory A970038 to Nav Canada on the topic of safety alert phraseology. In December 1999, the TSB again raised the issue of safety alert phraseology in Aviation Safety Advisory A990050-1. In response to Aviation Safety Advisory A970038, Nav Canada assured the TSB that the issue would be given wide circulation within the company and that the topic would be treated as a priority topic during the 1998 refresher training program. Nevertheless, the TSB's investigations into losses of separation indicate that controllers continue to be resistant to using the required phraseology to deal with safety-critical situations. In Aviation Safety Advisory A990050-1, the TSB noted that current and proposed defences against the threat of midair collision are not adequate and that there are undefended risks associated with controllers not being adequately prepared to reduce the potential for a midair collision once a loss of separation has occurred. The TSB suggested that Nav Canada may wish to consider taking action to better prepare controllers to reduce this potential. In September 2000, the TSB recommended (Recommendation A00-15) that Nav Canada commit, with a set date, to the installation and operation of an automated conflict prediction and alerting system at the nation's air traffic control facilities to reduce the risk of midair collisions. Nav Canada has implemented conflict-alert functionality in the Moncton ACC high-level sectors, and site trials are scheduled for some other ACCs during 2002.